
<div id="main-contentz">
	<div id="main-content-area" style="margin-top:60px;">
		<div id="main-content-wrap" style="height:560px;">
			<div id = "ad_wrap">
				<div id = "top-receptients">
					<h2 style = "float:left; color:#fff; font-size:14px; margin-top:10px; margin-left:10px" >Add Recipient</h2>
				</div>
				<div id = "con-recipients">
					<form id = "add_receptients_frm" name = "add_receptients_frm">
					<?php echo form_hidden('recipient', $this->uri->segment(3)); ?>

						<input id = "hidden1" type = "hidden" value = "<?php echo base_url();?>index.php/recipients/create_recipients"/>
						<input id = "hidden2" type = "hidden" value = "<?php echo base_url();?>"/>
						<input id = "check_em_exist" type = "hidden" value = ""/>
						<div class = "error-r"></div>
						<div class = "loader"><img src = "<?php echo base_url();?>assets/images/ajax-loader.gif" alt = "loader" /></div>
						<p class = "add-recep"><input type = "text" value = "First Name" name = "add-recep-fname" id = "add-recep-fname" /></p>
						<p class = "add-recep"><input type = "text" value = "Middle Name" name = "add-recep-mname" id = "add-recep-mname" /></p>
						<p class = "add-recep"><input type = "text" value = "Last Name" name = "add-recep-lname" id = "add-recep-lname" /></p>
						<p class = "add-recep">
							<input type = "text" value = "Address" name = "add-recep-address" id = "add-recep-address" style="margin-bottom:0px;"/>
							<div id="address_div"><span class="add_city">City</span> <span class="add_state">State</span><span class="add_zip">Zip</span></div>
							<div class="clear"></div>
						</p>
						<p class = "add-recep">
							<label class="fleft">Relationship</label>
							<select name="add-recep-rel">
								<?php foreach($relationships as $rel):?>
									<option value="<?php echo $rel['id']?>"><?php echo $rel['title'];?></option>
								<?php endforeach;?>
							</select>
						</p>
						<p class = "add-recep"><input type = "text" value = "Phone" name = "add-recep-phone" id = "add-recep-phone" /></p>
						<p class = "add-recep"><input type = "text" value = "Email" name = "add-recep-email" id = "add-recep-email" /></p>
						<p style = "margin-right:20px;" class="fright">
							<input type="button" value="" alt="" id="recep-submit" />
							<input type="button" value="" alt="" id="recep-cancel" />
						</p>
					</form>
				</div>
			</div>
		</div>
		<div class="clear"></div>
		<div class="rep_ads"><img src="<?php echo base_url();?>assets/images/ads_recipients.png"/></div>
	</div>
</div>